Sasigarn A Bowden, MD is a Pediatric Endocrinologist at the Nationwide Children’s Hospital, and an Associate Professor of Pediatrics at The Ohio State University College of Medicine. She is Board Certified by the American Board of Pediatrics (ABP) and Sub-Board of Pediatric Endocrinology. Her clinical and research interests include metabolic bone disorders, pediatric osteoporosis, and diabetes. She is the Associate Program Director for the fellowship program and a Pediatric Bone Expert for the Metabolic Bone Clinic at Nationwide Children’s Hospital. She is the Chief Editor for eMedicine and has published more than 60 articles and abstracts in reputed journals.

Osteoporosis is defined as a systemic skeletal disease characterized by compromised bone strength, and microarchitectural deterioration of bone, leading to fragility fractures. Once thought to be a unique health problem in older adults, osteoporosis has now been recognized as a condition also seen in pediatric patients. Osteoporosis in children has a broad range of etiologies, and is classified into 2 groups: primary osteoporosis or genetic bone disease, and secondary osteoporosis due to underlying chronic diseases. The diagnosis of osteoporosis in children should not be made on the basis of densitometric criteria alone. The presence of bone fragility with a history of clinically significant fractures and significantly low bone density are required for diagnosis of pediatric osteoporosis. Vertebral fracture in the absence of high energy trauma or local disease is pathognomonic for osteoporosis and can allow the diagnosis without detection of significantly low bone density. Monitoring for bone health should include screening for vertebral fractures that are common and often asymptomatic in children with risk factors for osteoporosis. Other diagnostic studies include biochemical markers of bone turnover, bone mineral density by dual energy x-ray absorptiometry, as well as spinal imaging using densitometric lateral spinal imaging. Optimizing bone health in children with osteoporosis includes treating the underlying condition causing bone fragility, and ensuring adequate weight-bearing exercise, vitamin D and calcium intake. Pharmacologic agents should be offered to patients with fragility fractures. Bisphosphonates have been used successfully in pediatric patients. This lecture reviews the latest advances in the assessment and treatment of pediatric osteoporosis.

 

 

Background: Vesicoureteric reflux (VUR) is an important association of pediatric urinary tract infection (UTI) found in 30 50% of all children presenting with first UTI. Contrast-enhanced voiding ultrasonography (ceVUS) has become an important radiationfree method for VUR detection in children. Its sensitivity in detecting VUR has greatly improved due to the development of the contrast-specific ultrasound techniques and the introduction of the second-generation ultrasound contrast agent, superseding the diagnostic accuracy of standard radiological procedures.

 

Aim: To discuss the first local pilot study performed in our institution on detection of vesicoureteric reflux by contrast-enhanced voiding ultrasonography with second- generation agent (SonoVue, Bracco, Italy).

 

Material & Methods: A total of 118 children with 236 nephroureteral units (NUUs) were evaluated using ceVUS. Age range 2 months to 18 years (mean: 6.4±4.9). Indications for ceVUS were acute pyelonephritis and recurrent urinary tract infection (62 children), hydronephrosis/small kidney (20 children) and control investigation for VUR during conservative management or after endoscopic correction (36 children). The majority of examinations were well tolerated without any adverse incident. One 3 months old girl where massive V grade VUR was detected, developed acute pyelonephritis as complication of the catheterization. Three children had painful micturation in the following few days, but no infection.

 

Results: VUR was shown in 62 (52.5%) children in 97/236 (41%) NUUs. It was unilateral in 47 and bilateral in 25 children. In 52 NUUs VUR was grade II/V in 26 Grade III/V, in 16 grade IV/V and in 3 grade V respectively. Urethra was shown in 90/118 children and in all boys, without major pathological finding. In 9 girls spinning top urethra has been shown. Subsequent urodynamic studies performed in 5 of them, revealed functional bladder problem.

 

Conclusions: Contrast-enhanced voiding urosonography using intravesical second generation ultrasound contrast agent could be recommended as a valid alternative diagnostic modality for detecting vesicoureteral reflux and evaluation of the distal urinary tract in children, based on its radiation-free, highly efficacious, reliable, and safe characteristics.